The URL can be used to link to this page

Home My Public Portal About9165-9167 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 8754(2-80) MISCELLANEOUS APPLICATION 1 hereby affirm that I have a certificate of consent to self "fl COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, ora certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800, Lab C) Policy No Company FOR APPLICANT TO FILL IN BUILDING ADDRESS ❑ Certified copy Is hereby furnished uiLDING s j�f. LOCALITY ❑ ADDRESS RJJ Certified copy is filed with the county building inspection I'll NEARES-f— department LOCALITY EM• ! -ir;IV CROSS ST Date Applicant ARE S; yy L 0 ♦/�+ DISTRICT NO P TYPE PROCESSED BY ROSS ST L {,/ �� I CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP GH"' No. �d (CIRCLE) STATE MAJOR SECOND LOCAL CL (This section need not be completed if the work involved NO. OF BLOCS. USE ZONE SPECIAL CONDITIONS O P TRACT NOW ON LOT V by the permit is for one hundred dollars ($100) or less.) USE OF ///►►► SIZE OF LOT EXISTING BLDG. J - crO I certify that in the performance of the work for which this C/ permit is Issued, I shall not employ any person In any manner U WNER so as to become subject to the Workers' Compensation Laws A01AIL O t�f�S OCCUPANCY GROUP w �S • v N-4 S 9 ADDRESS (L Date Applicant r aa ' NOTICE TO APPLICANT If, after making this Certificate of cirr LFj GSI No� ��J v OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLI ATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION 'deemed revoked. ❑ No Spec. Knowl. ❑ LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT (LIST ITEMS BELOW) NO. OF EXITS 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and . effect • REQ'D O PROVIDED O ^ PARKING 'cense Number Lic Class SPACES LIMITED TIME USE ('4ontractor Date DATE DATE FROM TO I am exempt from the licensing requirements as i am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S acting In my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE Inessand Professions Code) FINAL APPROVAL /7 ENT USE OF BUILDING � /+/{Ar, Lic.or Reg No Date / J✓V /•• t(LL/ (� HOME OWNER-BUILDER DECLARATION No of EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- 12 2 6.0 A ness and Professions Code) NO PARKING SPACES PROVIDED ❑ 1, as owner of the property, will do the work and the # 0.0 0 o g g I structure is not intended or offered for sale (Section' 0 0 0 0 0 0 0 0 7044, Business and Professions Code). OPOSED USE OF BUILDING CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency OFS for the performance of the work for which this permit Is issued (Sec. 3097,Civ C) Lender's Name PROPOSED MAX OCC. Lender's Address _ PERMIT FEE I certify that I have read this application and state that the above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter u nipt Aab e- ntione roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee /J [ j///ate WORKERS'COMPENSATION DECLARATION CE 875 (11-84) M I SC E L LA N EO U S APPLICATION CE 875 I Hereby affirm that I have a certificate of consent to self -NDISAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or �COUNTY OF LOS ANGELES BUILDING A,- a certified copy thereof(Sec. 3800,Lab C) ' Policy No. Company FOR APPLICANT TO FILL IN BUILDING + ADDRESS Certified copy is hereby furnished ADBUD- .,-.' INSS G .Y � � "1)/ LOCALITY I El Certified copy is filed with the county building inspection OCALITY NEAREST department. I jut - CROSS ST Date Applicant NEAREST DISTRICT NO I GROUP TYPE PROCESSED BY CROSS ST CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO, BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF BLDGS (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this 1 o r'� permit is issued, I shall not employ any person in any manner %OWNER of building: U IIIfJIII so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP ce C:3 Date Applicant ADDRESS iir. t NOTICE TO APPLICANT• If, ter making this Certificate of CITY NOI �a�(,f/ �. OCCUPANT LOAD Exemption, you should ome subject to the Workers' — Compensation provisions e Labor Code, you must forth AP (CATION FOR EXIT HARDWARE with comply With S h O inions OI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED NTRACTORS DECLARATION OCCUPANCY INSPECTION 9 I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busr SAFETY PERMIT ❑ LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code, and my license is in full force and effect. Name of Business . PARKING �i SPACES REp*D D PROVIDED �_ I J License Number Lia Class LIMITED TIMEN9 FEE Contractor Date DATE DATE i il'll4` I am exempt from the licensing requirements as I am a FROM TO - - - licensed architect or a registered professional engineer SIZE OF NO. OF ii-3J-[f�i,ISPECTIQl2 S acting in my professional capacity (Section 705I, Bus- EXISTING BLDG STORIES _ SIGNATURE I 1 mess and Professions Code). �� FINAL APPROVAL PRESENT USE OF BUILDING Lic or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ? �� ON LOT AND USE 1 hereby affirm that I am exempt from the Contractor's I�Q License Law for the following reason (Section 7031 5, Busi- ness and Professions Code). NO. PARKING ❑ I, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY �IPROPOSED USE.OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ C.). Lender's Name PROPOSED MAX. OCC Lender's Address I certify that I have read this application and state that the PERMIT FEE 25 . 00 above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 25 . 00 upon the above-mentioned prop ty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Sign t re of Permittee Date 77'- WO"ERS'COMPENSATION DECLARATION CE 875(11-84) , MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN ABUILDING DDRESS (p `, Certified copy is hereby furnished BU' LDIN LOCALITY ADDRESS S S a Y•(V�-• Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST Date Applicant NEAREST DISTRICT NQQQ= GaouTYPE P ESSED BY CROSS ST. // 11/] CONST CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL a b��J f/�C_ COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO OF BLOCS NO. (CIRCLE) (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF SIZE OF LOT EXISTING BLDG I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNERv so as to become subject to the Workers' Compensation Laws MAIL 5� OCCUPANCY GROUP ® o , � IVT! JQ E3 Date ADDRES Applicant � NOTICE TO APPLICANT: If, after making this Certificate of cIT ✓R� NOLiL OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be TRAILER USE EJ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked p LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices El I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi SAFETY PERMIT LIST ITEMS BELOW NO OF EXITS ness and Professions Code, and-my license is in full force and ��Q effect IKU PARKING SPACES REQ'D PROVIDED License Number Lie Class C-1 - — 71 �A ESTi�T� �/v! LIMITED TIME USE Contractor Date DATE DATE F1I'am exempt from the licensing requirements as,I am a FROM TO licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES - —lt"sw ATT�U,R,EE iness and Professions Code) y�y FINAL APPROVAL J O�—q� �EE�ji�r��i7 Lie.or Reg.No Date PRESENT USE OF BUILDING 7 ON 7 i i,lUs L,—lfl_,L1 __i c"I HOME OWNER-BUILDER DECLARATION NO OF EXISTING BUILDINGS _ ON LOT AND USEPM r+'o y,l I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING El1, as owner of the property, will do the work and the SPACES PROVIDED O 1 structure is not intended or offered for sale (Section 7044,Business and Professions Code) CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDI i �r /C� / I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is OY IV` issued(Sec 3097,Civ.C.). Lender's Name ' PROPOSED MAX OCC. Lender's Address I certify that I have read this application and state that the PERMIT FEE , above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE upon the above mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Signature of Permittee Date WORKLRS' (OMPLNSAI[ON DE(LARATION ;;M ',I PLN,, ,,( MISCELLANEOUS APPLICATION I hereby affirm that I have a ceitilicate (ll LonscJu i,, sell COUN_IY OF LOS ANGEL CS BUILDING AND SAFETY DIVISION IJ Insure,or a certificate of Workers (On1pLIlsatlon IlIsLll.,11LC, of a certified copy thereof (Sec 3800 Lab C) Policy No _ Company FOR APPLICANI TO FILL Ill BUILDING BUILDING ADDRESS ADDRESS ❑ Certified Lop) is hereby furnished R / �y�)y L /�� LCA �wtnas f/Y LOCALITY ❑ Certified copy Is I(led with the count) bulldnlg nr['cLIlon CITY le !, ZIP department (/ �� 9 ��O CROSS NEAREST Dale Applicant SIZE OF LOT NO OF BLDGS NOW ON LOT DISTRICT NO GROUP TYPE PROCESSED BY CONST L' (ERTII IC'AI-L OF EXEMPTION 1 ROM WORK I 'ti TRACT BLOCK LOT NO (_. COMPENSAI ION INSURANCE MAP HIGHWAY l NO (CIRCLE, STATE MAJOR SECOND LOCAL (This section need not be compleled If the Noll( ilnolled ASSESSOR MAP BOOK PAGE PARCELr= by [he permit is fol one hundied dollars (b100) in less USE ZONE SPECIAL CONDITIONS l 1 cellily that in the pert LllnldllLC of IhL \folk 101 Mfrs_11 [Ills OWNER TEL NO --- [ i permit Is Issued. I shall not employ an) pelum ul .ul) manner so as to become subject to the Workers' (oinpen,aww Laws ADDRESS OCCUPANCY GROUP r" I [ Date _- AppIlLdot CITY ZIP NOTICE TO APPLIC'ANI II Awl making This ( ei;il(Late OCCUPANT LOAD of Exemption, jou should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation pro\islons of the Labor Code jou must lorthwlth Comply With Such provisions or this perllllt shall be deellled TRAILER USE❑ GEOLOGY INSPECTION❑ No Spec Knows ❑ revoked LICENSED CON'(RAC 1016 DL( LAK %[ION OCCUPANCY INSPECTIONK Panic Devices ❑ ? I hereby aft irm that I ism licensed under Ill ovlslons of (hdptef SAFETY PERMIT❑ ILIST ITEMS BELON) { I 9(commencing with Section 7000)of Dix Islon 1 of the (3uslness NO OF EXITS �{ 3 and Professions Code ofd Illy license Is In full forLC all.) effect t� cf Qa(L' LtL�S'y License Number I IL ( Elis 1 L PARKING REQ'D D PROVIDED D SPACES _ 1 I Contl,lCtor Date / LIMITED TIME USE DATE DATE a ❑ 1 am exempt from the licensing re011llenlents ds I dill I FROM TO licensed alchltect or d registered plole,,slonal .rigincer f acting Ill illi pt(1IL'sUl)Ildl LdpdL'll) (Section 7tlll Il11sIllCss SIZE OF NO Or INSPECTOR S SIGNATURE EXISTING L3 L-UG STORIES_ and Plolcsslons (ode 1 _ LIC Or Reg No Date PRESENT USE OF BUILDING FINAL APPROVAL 1 IIOML OWNLR-BUIL DLR DI ( l Al(Al ION NO Of LXISIINGBUILDINGS ON LOT AND USE hereby affirm that I and esenlpt Mont the Contiactol ' I ILCIISe – Law for the following lesson (Section 70315 Busoless and Professions (ode) NO PARKING � El I .Is owner of the plopelt) LL ill du Ilse LL,uk and Ibr SPACES PROVIDED — -------- StIIIClllre 11 not intended of 011Cled 101 s,Ile (1CLi-on Mill PROPOSED USE OF BUILDING S�YVI�C.e Business and Professions Code) I CONSTRLJ(TION LENDING AGLN( Y hereby alflnll that thele n a construction lending ,IcenLy fol -- — the performance of the work for llhlch Ihls pclnllt is Issued (Sec 3097, Civ C ) PROPOSED MAX OCC Lender's Name APPLICAN Ip:TJ TEL NO Lender's Address ADDRESS t3 1 certify that I have read this application and stall. that the �al 6-6 above infortmation Is corre Lt 1 agree to comply with,11(ounty PERMIT FEE ordinances and State laws relating to building constru, ion,and hereby authorize Lepresentatives of this County w entLI Upon ISSUANCE FEE the above-mentioned property for nlspeLti011 purpos,s TOTAL FEE X � SFC REVERSE FOR EXP(ANATORY LANGUA(,E Signature of Pern itee Date I _ WORKERS'COMPENSATION DECLARATION 76M444_ MISCELLANEOUS A P P L I C A T I O N I hereby affirm that i have a certificate of consent to self CE 875 (11-84)COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.). Policy No Company BUILDING FOR APPLICANT TO FILL IN ADORES FlCertified copy is hereby furnished. r��w..+l��--- 9UICDIN. l� I ADDRESS� LOCALITY ❑ Certified copy is filed with the county building inspection -LOCALITY NEAREST department. [y � Ct6 / CROSS ST. Date Applicant � NEAREST / DISTRoCT UP TYPE CE3SED BY CROSS ST. .J. CO CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL te COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY STATE MAJOR SECOND LOCAL NO. OF SLOGS NO ICIRCLEI (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF I certify that in the performance of the work for which this SIZE OF Lor QEXISS TSI N/G BLDG. a permit is issued, I shall not employ any person in any manne `oWNER:of=buldn I (•/1� so as to become subject to the Workers' Compensation Laws. 1 OCCUPANCY GROUP O_ MAILDate Applicant ADDRESS y/�� 1�7 lj�] NOTICE TO APPLICANT: If, after making this Certificate of CIT no� OCCUPANT LOAD vJ Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APPLI ION FOR EXIT HARDWARE With comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION ❑ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code, and my license is in full force a ---- T—.---� effectx_Name =o_f_business PARKING (� SPACES REpD D PROVIDED � I License Number Lie Class Liu 1" ZAZ -WU ryao4 cd. J /t LIMITED TIME USE Contractor DateUSA C DATE DATE ElI am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OF NO. OP INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIG ATURE iness and Professions Code) P FINAL APPROVAL PRESENT USE OBUILDING GQ Lie or Reg.No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE Op [ hereby affirm that I am exempt from the Contractor's j- , 1, License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO. PARKING DI, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED use of BUILDING f �� I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C). Lender's Name PROPOSED MAX. OCC Lender's Address I certify that I have read this application and state that the PERMIT FEE 25 . 00 above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, d hereby authorize representatives of this County to enter TOTAL FEE 25 -00 on the above-mentioned pr per for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE X �7! —XX 6X Signature of rmittee Ditte ` „ORI:LRS'('°%IPLNS-\Tl°N- DE(L\RMON 76M444 MISCELLANEOUS APPLICATION r17 I hereby atflrm that I have a certificate of consent to Self CE aye )1 aa) r insure or a certificate of \lorkers Conioens,ttlon Insurance or COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION a certified copy thereof +Sec 3801) Lab C Polic} No _l )mDa ny FOR APPLICANT TO FILL IN PIDDRESS 0i6Llx rAe, Certilied cop} Is hereb} turmshea X BUILDING 67 L S �/✓� S !�� LOCALITY ADDRESS 7L 1 ❑ CeILlfled Copt IS fIIC[l Rlth [tie )lnf) bu ddlRl' Ln Spel'[IOIl LOCALITY 'EAREST department Temple City C,.4 /;7J-cy CROSS ST Date kDt I1LaI1[ NEAREST / 0 d CXIC I�/"�� ISTR NO GRp UP TYPE ROC ESSED BY CROSS ST L ,I eG (,J//( CONS + CLRTIFIC ATE OF E\ENIPTIO\ FROM '\ORKERS I LEGAL t 0%IPFNS\TIOrs' [N«R\fit 1 OESCRIPT•ON LOT VO BLOCK I MA' .+IC Iaw Av r+O STATE MAJOR SECOND LOCAL NO JF SLOGS [CIR CLE( (This section need not be con Dieted if the Ivork Involved -qAC- NO IV ON LOT USE ?ONE SPECIAL CONDITIONS by the permit is for one hundred dollars MOO) or less.) USE OF I T 1 I certify that n the Dertnnnan e i -hein 4 'o lbich his SIZE OF LOEXISTING BLDGJJ _ permit Is issued 1 shall not employ ans ne-son nam manner OWNER /yJAR 4xt�T 1fu��-�0- So as +o become subject ;o the `\orkers I .nvensatinn Lacs MAILE55 OCCUPANC' :;ROUP ROUP ,C - AD OR f Date /� z � ' �- -S\pvllcant�.sa.4 A. /-Cp46'S C116 v NOTICE TO \PPLIt'\NT If .0 er m kmc 'w �crltctte nt c T NO OCCUP^.N- LOAD E\emvttu-I x ou ,hould become ,unlet; o •h- Tc C�rY ��b -� o CUmpens,,tron vro%islons of cite Labor• ,,ae roil Must fnrTh- 1 APDL'CATICv z'�F =_X17 yo,rlll ,-= S villi cmnnn ,vith ,uch ^ro rs,,lm hl. -emit shall be -RAILER JSE iJt �j ,t GEOLOGY NcP�t=T`p'J No Scec K-ic,vl deemed :e\ol.ed — ` OCCUPANCY INSPEC-10Ngg Panic Dev,ces a - LIC ENSLD L ON1 R ACTORS DECL�R�TlO`: I hereb} atflrm :halt 1 am licensed under Dreviwns of Chavter SAFETY PER IT (LIST ITEMS BELDIV) 9 (commenLine With Section 000) of Dnlslon ' .)t the BL1S1- u NO OF EXITS ness ,Ind P-ntessions Code and my license is In 'ml tore- and etfec; PI"RKING REO O I I 'ROVID ED 5 I'C C E S L-�l License \tiinher L,c Clas, LIMITED TIME USE N Contractor Date __ TATE DA'E W z I'M TO l am exempt from the licensing reaulrenients is I am I m i licensed archlrect or a re_arstered nmtessronal engineer ;IZE OF ND of INSPECTOR S z actino �n ,m prct•c,sional _trI;r -ncl BLIT- EXISTING BLDG ;-ORIE3 *NAmess nj P-ofessicn,I,octetFINAL APpROV4LD "RESENT USE OF BUILDINGLIc or Re^_ �0 1�-T '15-HO`•lE O\\NFR-BLILDER DECL1R \TION No of EXISTING BUILDINGS ON LOT AND USE -+ ' I hereb}• affirm that I am exempt rmnt the Contractor s License Lav+ for the follo)sim, reason (Section "031 _; Buv- ness and P-otesslons Code) NO. PARKING ' El1, as ,loner of the propert} «dl do he work and the SPACES PROVIDED struc;I re Is not Intended or otfered tor .ale (Section f 7044 Buslne,s and Prulessions(odel CONSTRICTION LENDING X PROPOSED USE OF BUILDING hereb) affirm that there Is a constriction lendme a2enev �a u I for the performance of the cork for uh1LI1 this permit Is Issued (Sec 3097,Civ C 1 Lender s Name Lender's \ddress PROPOSED MAX OCC _ _ /� 1 cerufv that I have read this application and state that the PERMIT FEE 25.00 above Information Is correct 1 agree to comply with all County ISSUANCE FEE ordinances and State laws relating to bulldmi construction, and hereby authorize representatives of this County to enter TOTAL FEE 25.00 I upon the above-mentioned propert} for Inspection purposes SEL RCVERSE FOR EXPLANATORY L,1NGU \GC-. " Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 C� I hereby affirm that I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION U insure, or a certificate of Workers'Compensation Insurance, e,or a certified copy thereof(Sec. 3800,Lab C) Policy No Company BUILDING �d FOR APPLICANT TO FILL IN �� ADDRESS Certified copy is hereby furnished BUILDING /}!/5r , A^5 (LrA/�� pR, -.�eLE LOCALITY XX ADDRESS 7` U7 L (f� IYC['�Y �LYI.{ L` - i ❑ Certified copy is filed with the county building inspection LOCALITY t, NEAREST department. yy, Sf�'M� �QV CROSS sT. TA department. Date Applicant NEAREST DISTRICT NO. GROUP TYPE P CESSED BY CROSS ST _ON6�N7A O -,� CONS CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NO (CIRCLE) STATE MAJOR SECOND LOCAL NO OF BLDGS. ' (This Section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) uSE OF I certify that in the performance of the work for which this slzE of LOT EXISTING BLDG. o Permit is issued, I shall not employ any Person in any mann�X OWNER of bul 1 C-.> so as to become subject to the Workers' Compensation Laws MAIL �1c�e2 OCCUPANCY GROUP o ADDRESS 1� U Date Applicant ,,, NOTICE TO APPLICANT If, after making this Certificate of CIrY brNOL( �� OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR E=XIT HARDWARE Compensation provisions of the Labor Code, you must forth- � ' with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. Panic Devices LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION EJ 1 hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT Q (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO OF EXITS ness and Professions Code, and my license is in full force anX effect Name of business PARKING REQ•D PROVIDED SPACES ll�� License Number Lic Class LIMITED TIME USE Contractor Date DATE DATE FROM' TO: I am exempt from the licensing requirements as I am a licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTORS acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. \ STORIES SI ruRE iness and Professions Code) FINAL APPROVAL PRESENT USE OF BUILDING 3 Lic or Reg No. Date HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO. PARKING ElI, as owner of the property, will do the work and the SPACES PROVIDED structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDING I hereby affirm that there is a construction lending agency PAVEL A�t*,ICY for the performance of the work for which this permit is issued(Sec. 3097,Civ.Q. Lender's Name x , PROPOSED MAX. OCC T Lender's Address PERMIT FEE I certify that I have read this application and state that the25 - 00 above information is correct I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, I and hereby authorize representatives of this County to enter TOTAL FEE 25 . 00 upon the above-mentioned property for inspection purposes 1' / SEE REVERSE FOR EXPLANATORY LANGUAGE µ XX XX SI i lure of Pernnttee Date GOUN TY OF . LOS �_�GELES DEP__RTIIE-NT OF PUELIC WORKS CA.''"T:) 7. `/.'1-_LLEY R:G_()ITATi CFF-1 CE EuILDING A`�D SI-77-TY 125 S. Baldwin Avenue Arcadia, CA 51007 (818) 574-09=1 MICROFILM I-H-F OR-1 iTION Record Sea--c:! 1933-195" � , Eur 1lain-A_ao�ress :�. �' �� 2 i _C6 `YVC6 (, Locali tY V , C Previous A_ddre-=s 1 �_l 314 1 �j I/2 ST Tract No. Lot No. Lot Size uilding P rmit if Issue ate Final Date crioticn of work Sa. Ft. B ild\Pet ssue Dat_ Fi •1 ateD crW rk S Buil ing Permit 7 Issue Date Final Date- Description of Work Sq. F- Euildir,ermlt ,� ssue Dat Fin 1 D to Descri or 1•7 rk So. Building Permit T Issue Date Final Date Lescrintlon of j'lork Sa. Ft. Se:•;er Permit T Date Issued Private Disposal Syste- D_-'� Inspect_d Public Seaver Connection: Date : C Ey: \�